To say this last year 2020 has been difficult for us all, is a gross understatement. The pandemic, which I dare anyone to say that they anticipated, has turned everyone’s life upside down including our professional life.
With the spread of Covid 19, the intentional steady and deliberate timelessness of the analytic endeavor was brought to a crashing halt as analysts and patients scrambled to find safety. In a curious manner, it was worse than any imagined foreign enemy or violent attack. The enemy was nowhere and everywhere at the same time. It seemed benign, as many affected individuals appeared to exhibit symptoms on a par with the flu, and yet, as we all know after well over 400,000 deaths in the United States alone, very deadly. It was impossible to assess the risk both of contagion and morbidity for ourselves and perhaps even more importantly for patients.
Covid has impacted all of us and I have been asked to offer a few of my personal impressions of the effect of this pandemic on my practice. I remember how stubborn I was as the case numbers began to rise and how resistive I was to accept this threat posed to my work as a psychoanalyst. I had fantasies of changing sheets covering the couch each hour which I imagined would prevent the next patient from falling ill. I had transient omnipotent fantasies that I was somehow immune, that if I washed my hands enough or sat back far enough in my chair, I could be safe from infection. Further reflection led to an inevitable breakdown of my denial and with this came the clear realization that I could not allow my patients to become infected or transmit this illness from one to another through any contact with me. After several nights of poor sleep, I decided the only safe and reasonable alternative, which less than one week earlier had seemed obscene, was to leave New York. I remember the day, Friday the 13th, when I beat a hasty retreat to my country house, struggled to obtain high-speed Internet and converted my practice to virtual interaction.
Along with feelings of relief at having found a haven from the scourge, I began to entertain a number of wishful fantasies/misperceptions of Covid which I suspect were not uncommon. The first and most irrational of these was a refusal to accept the uncertainty of any time horizon for this disease. As I searched for a metaphor to help me think about this illness my mind seized heroically on the Battle of Britain or more pedantically, a bad bar fight. I thought that like in countless Westerns, the important thing was to duck below the bar, wait for the mirror to be smashed, or a couple of chairs to be thrown, and then emerge in time for the clean-up.
Somewhere I knew better. Early on Dr. Fauci was predicting a “winter surge” but to contemplate a disruption lasting many months was simply unimaginable. My sticky and silly notions, neither the one that I would not have to interrupt my practice and reimagine working as a psychoanalyst remotely, nor the idea that perhaps at most it would be three to four months before a return to “normality” were either correct or I suspect, uncommon. With just such a mindset, I remember writing a post to the membership asking for recommendations regarding resuming my office practice. Happily, one or two responses were sufficient to disabuse me of either notion, but I remember feeling ashamed and helpless at my inability to process the magnitude of what had befallen our profession, to say nothing of our city, our country, and the entire world.
It is perhaps a special irony that I write this ten months later, one day after receiving my first dose of the Moderna vaccine. Even as I look ahead to a time when we can all attempt to resume our practices, I am aware that several things have perhaps changed forever. As is true with any change in life, it can represent at once an advance and a retreat.
At the most basic level, one change that will likely remain is the idea of treating remotely. Without question virtual sessions have represented a significant savings in travel time and energy. I do not know what will happen vis-à-vis insurance reimbursement, but I suspect that many of my patients, especially those who see me in analysis four and five times a week and who do not reside in Manhattan, will prefer one or maybe more of those sessions to be virtual. More generally, no matter our efforts to “hold the line”, I also further suspect that most of us will allow some increased flexibility in the use of remote devices. During the pandemic patients were able to access care at an increased frequency in part because of the requirement that they were directed to work from home and structuring their workday as they wished allowed them to receive treatment when convenient remotely over the Internet. I cannot speak for any other analyst but there has been hardly a spare hour and in almost all cases increased contact was the outcome.
On balance this can be viewed as a positive. On the negative side, I believe that both Zoom or telephone session leave something important out of the therapeutic encounter. Of the two, Zoom appears to cause greater damage; on the surface, (pun intended) it is not completely clear why face-to-face Internet contact has felt the greater step backwards. Initially the advantage of seeing the live image of my patients and vice versa seemed obvious and of incontestable value. However, this “plus” I suspect mostly served in my unconscious, to reassure me that my practice had not disappeared. Yet in my initial encounters with patients, I was somehow not surprised to find that most of my patients preferred primarily aural contact, as via the telephone, to Zoom. Even when patients expressed a desire for some face-to-face contact, most of my patients chose to then turn the camera to the ceiling or floor opting to see me physically only at the beginning and end of every hour.
In trying to make sense of this, I recalled, when perhaps reading a biography of Helen Keller, that because she was denied certain sensory modalities, she found reflexively that all the ones that remained were heightened in their intensity. The same process seemed to be at work in the psychoanalytic hour by telephone. It felt that not having the superficial comfort of seeing a familiar image, forced both me and my patient to think/feel our way into the space between our disembodied words while pondering the fantasies/memories that were being represented and responded to by me. In the time that has followed I have come to appreciate this “less is more” way of working, different than in the office. I have had to pay heightened attention to the tonal qualities of my patient’s voice, to the rate of his/her breathing, to the spaces between words and the significance, both emotional and ideational, of each of these in a way that is not as readily discernable as when my patient is lying on the couch in front of me.
As I thought about this, I realized it made sense that the primarily aural contact would demand a heightened level of alertness and focus. Unlike on the couch, I don’t get to see the person’s face. I don’t get to watch how they react to material as I would in my office. I don’t see the emergence of tears of sadness, or manifestations of rage, or pleasure, or irritation, or frustration that show up on a person’s face frequently not immediately embodied in the words that are uttered. I don’t have the opportunity to see their bodies as, in Kabuki-like fashion, they enact their conflicts. But that is only one half of the story of loss.
The other, and greater deficit occurs as a consequence of our patients being unable to experience our physical presence in their world. Physicality means a lot more than we give credit in our daily work. I was alerted to this by an analysand, a cancer doctor, who, speaking of her imminently dying patients, stated with utter seriousness: “I owe them a good death.” Pre-Covid, that meant for this patient being at the bedside, holding the patient’s hand, listening to family members and absorbing the tears and stormy fury of all involved at losing everything. While pleased herself, post-Covid, as a result of telemedicine to be available for consultation on chemotherapy options worldwide she bemoaned suddenly, because of Covid, almost never being able at the bedside, and when afforded such an opportunity, being required to be covered and “hidden” in PPE, gowns, masks and the like.
It was while working with this patient that I came to appreciate the importance she attached to the physical apperception of my body and the core sense of safety and security associated with that experience. Early on, she complained wistfully that she missed hearing my stomach rumbling and that she felt reassured by the smell of coffee that has forever been part of my professional life and office. Over the ensuing months, she has, while anxiously asserting the value of our tele-sessions, acknowledged how somehow things “don’t feel right” even though I continue to see her five days a week.
It was this and other “virtual” analyses which helped me recognize that there was something around the physical “togetherness” of the dyad, a kind of confidence that emerges from just being at peace and in safety with another over a long period of time that is signally important for mutagenesis. It reminded me of the observations of Bertram Lewin who likened the position of the analyst who sits behind and the analysand who lies on the couch to that of a nursing mother with her child in front on her lap. If one thinks about how immediately loving and reassuring such a situation would be in a normal mother-child situation, it is easy to appreciate the sense of containment and safety provided under usual analytic conditions and which simply cannot be duplicated under virtual conditions.
In no way do I mean to imply that work done over the Internet is without substance or value. In these strange and difficult times, with the imposed economic and social restrictions mandated by quarantine, our efforts to manage stress and reassure with empathy and concern has been vital. However, I suspect that we are all in our own way responding to what is missing from the normal analytic setting. Again, I have no statistics, but I believe, on balance, there is a larger share of “supportive work” done pushing the treatment in the direction of a dynamic psychotherapy versus true psychoanalysis.
And even with, or just perhaps because, we are trying to compensate for a poorer quality of experience, I believe we can do less, change less. I see the analytic work as proceeding in stages which are affected in varying degrees by our retreat to a virtual world. There is the earliest part of any analysis focused on helping the patient understand the notion of free association while beginning to identify defenses against ideas and feelings. There is a second phase which constitutes the exploration of traumatic and problematic relationships and the sorting out of unconscious fantasies via historical reconstruction and transference. These two phases seem less impacted by virtuality than the third phase which, in my experience, has been crucial. I liken it a little bit to a seesaw: there is a moment at which what was down goes up and what was up comes down; a fulcrum in which the patient not only understands his/her difficulties but has an incipient capacity to change the future, to derail the automatic way in which he/she reinvents yet another version of his/her conflict. There is the possibility of growth and change but it has yet to occur and it is at this juncture that virtual treatment performs its absolute worst.
Again, I can only offer anecdotal evidence but in thinking of the effects of this accidental social experiment there are least four of my analytic patients who seem to be in this situation of “betwixt and between” for months. I have scratched my head looking for something to interpret, focusing on “working through” but feeling increasingly exhausted. It is currently my belief that what is missing is the effect of the dyad, the physical dyad. It is my conviction that, due to the requirement of a virtual interaction, the full satisfaction of being with a benign powerful Other, and able to internalize in ways that are beyond words something of the preconscious confidence and optimism that we offer our patients, that they can change their lives falls short.
Clearly all this could be a result of many factors and there is much to learn from how these treatments proceed in the present format and later, when it hoped we can resume working under more optimal conditions. But I think the canary in the Covid mine, may finally be a theoretical and personal reluctance to fully appreciate what being physically close to and with our patients means, not for “a good death” as with my cancer analysand, but for a better and more satisfactory life.